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BASIC INFORMATION
SYNONYMS
Multidrug-resistant Staphylococcus aureus
Oxacillin-resistant Staphylococcus aureus
ICD-9CM CODES
041.12Methicillin-resistant Staphylococcus
aureus in conditions classified
elsewhere and of unspecified site
ICD-10CM CODES
B95.62Methicillin-resistant Staphylococcus
aureus infection as the cause of
diseases classified elsewhere
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE: 1:3000
PEAK INCIDENCE: Occurs year round; may peak
during summer and fall months for CA-MRSA
PREVALENCE: The national rate of MRSA colonization or infection is 46.3 per 10,000 inpatients. Hospital prevalence rate of MRSA is as
high as 60% in hospitals, which means that
60% of S. aureus strains in that hospital will
be MRSA.
PREDOMINANT SEX AND AGE: All ages and
both sexes
GENETICS: NA
RISK FACTORS:
HA-MRSA: hospitalization; invasive medical
device; residing in long-term nursing facility
CA-MRSA: initially seen in young men
engaged in athletic activities and in gyms,
prisons, military barracks, etc., but has now
spread to the entire age spectrum including
neonates and the elderly.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
CA-MRSA: can present with skin infection,
associated with opening in the skin; red
bump, pustule, or boil; erythema, swelling;
edema, often fluctuant and very painful
HA-MRSA: bacteremia; infection associated
with intravenous device
1. Catheters: pneumonia
2. Skin: cellulitis
3. Bone: osteomyelitis
4. Endocarditis
5. Abscesses: skin or organ
6. Pneumonia: nosocomial
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Skin: spider bite (many patients with CA-MRSA
feel as if they were bitten by a spider)
Cellulitis: other organism(s) such as streptococci and methicillin-sensitive S. aureus (MSSA)
Pneumonia: not due to MRSA
Bacteria: not due to MRSA
WORKUP
Culture of wound, abscess, blood, sputum;
rule out colonization; culture of nares or axillae
LABORATORY TESTS
See above.
PFGE: usually done only for epidemiologic or
outbreak purposes.
IMAGING STUDIES
Radiographs or computed tomography scan
of suspected organ
Echocardiogram: all adult patients with
S. aureus bacteremia should undergo
echocardiography
TREATMENT
CA-MRSA: oral antibiotics that may be effective include trimethoprim-sulfamethoxazole,
doxycycline, minocycline, or clindamycin;
linezolid is another option but very expensive.
HA-MRSA: intravenous antibiotics, vancomycin, linezolid, daptomycin, tigecycline
NONPHARMACOLOGIC THERAPY
Abscess surgically drained
ACUTE GENERAL Rx
Trimethoprim-sulfamethoxazole, one doublestrength tablet PO bid, is useful in cases of
CA-MRSA since 95% of community-acquired
MRSA strains are susceptible to it invitro. Other
agents that can be used for CA-MRSA include:
1. Clindamycin: 300 to 450 mg q6-8h also
inhibits toxin production. If strain tests
sensitive to clindamycin but resistant to
erythromycin, then a D test must be
done to ensure there will not be inducible resistance while on therapy with the
clindamycin.
2. Doxycycline: 100 mg PO q12h and minocycline also have some activity against
MRSA.
3. Rifampin: never used alone but can be
used with one of the other oral agents
Vancomycin 15-20 mg/kg IV q8 to 12h
is the mainstay of parenteral therapy for
MRSA infections. There is an increasing concern of MRSA strains developing tolerance
to vancomycin, requiring higher doses to
achieve eradication. True vancomycin resistant strains (MIC 32 mg/L) remain rare.
Vancomycin trough levels of at least 15 to
20 mcg/ml are recommended to treat MRSA
infections.
Linezolid 600 mg PO or IV bid is a synthetic
oxazolidinone FDA-approved for MRSA skin
and soft tissue infections and pneumonia. It
has been shown to be more effective than
vancomycin for MRSA pneumonia. However,
its cost is more than 10 times as much as
vancomycin.
Daptomycin: 4 mg/kg/day to 6 mg/kg/day
IV is approved for skin and soft tissue infections, bacteremia and right-sided endocarditis but should not be used for pneumonia as
it is inactivated by pulmonary surfactant.
Tigecycline: 100 mg IV load, then 50 mg IV
q12h, is approved for MRSA skin and soft
tissue infections and intraabdominal abscess.
Ceftaroline is a fifth-generation cephalosporin, also effective against MRSA but only skin
and soft tissue infections, not pneumonia:
600 mg IV q12h.
CHRONIC Rx
Patients with MRSA colonization may have
reexposure or may be unable to eradicate
colonized state.
Oral agents used to attempt eradication of
colonization are rifampin, tetracycline, and
minocycline.
COMPLEMENTARY &
ALTERNATIVE MEDICINE
Mupirocin ointment may be administered to
the nares to attempt to decolonize; it can also
be applied to infected skin sites.
Chlorhexidine 2% or 4% wash may be used
to lower skin burden of colonization.
EVIDENCE
Available at www.expertconsult.com
SUGGESTED READINGS
Available at www.expertconsult.com
AUTHOR: GLENN G. FORT, M.D., M.P.H.
Diseases
and Disorders
DEFINITION
Methicillin-resistant Staphylococcus aureus
(MRSA) is a common bacterial pathogen with
resistance to many antibiotics. It is defined as a
S. aureus that shows a minimum inhibitory concentration (MIC) of greater than or equal to 4 mcg/
ml to oxacillin. There are now two types of MRSA:
HA-MRSA: hospital-acquired MRSA, usually
multidrug resistant
CA-MRSA: community-acquired MRSA; an
emerging pathogen, usually acquired outside
of the hospital setting; resistance may differ
from HA-MRSA and is generally susceptible
to more antibiotics than HA-MRSA
ETIOLOGY
CA-MRSA: the most prevalent strain in the US
on pulse field electrophoresis (PFGE) is called
USA 300
1. CA-MRSA: common cause of skin and soft
tissue infections in the emergency room.
It can, however, also cause necrotizing
pneumonia, sepsis, osteomyelitis, etc.
2. Virulence factors particular to CA-MRSA:
Panton-Valentine leukocidin (PVL) toxin,
alpha-hemolysin toxin, phenol soluble
modulins, etc., that enhance ability to
cause infection
HA-MRSA: most strains on PFGE are USA 100
or USA 200 and tend to have multidrug resistance. Patients with HA-MRSA infection have
higher mortality and morbidity than patients
with a methicillin-sensitive S. aureus (MSSA)
infection.
797
Results:
Eight trials encompassing 1,641 subjects met entry criteria. Linezolid
was not superior to glycopeptide antibiotics for end points of clinical success (relative risk [RR] linezolid vs glycopeptide, 1.04; 95% CI, 0.971.11; P = .28), microbiologic success (RR, 1.13; 95% CI, 0.97-1.31; P =
.12), or mortality (RR, 0.91; 95% CI, 0.69-1.18; P = .47). In addition, clinical success in the subgroup of subjects with MRSA-positive respiratory
tract culture (RR, 1.23; 95% CI, 0.97-1.57; P = .09) was not significantly
different from those without MRSA (RR, 0.95; 95% CI, 0.83-1.09; P =
.48), P for interaction, 0.07. The risk for adverse events was not different between the two antibiotic classes (RR, 0.96; 95% CI, 0.86-1.07;
P = .48).
Conclusion:
Randomized controlled trials do not support superiority of linezolid over
glycopeptide antibiotics for the treatment of nosocomial pneumonia. We
recommend that decisions between linezolid or glycopeptide antibiotics
for empirical or MRSA-directed therapy of nosocomial pneumonia depend on local availability, antibiotic resistance patterns, preferred routes
of delivery, and cost, rather than presumed differences in efficacy.
Evidence-Based References
Rubinstein E: for the ATTAIN Study Group. Telavancin versus vancomycin for
hospital-acquired pneumonia due to gram-positive pathogens, Clin Infect Dis
52:3140, 2011.
Walkey A etal.: Linezolid vs glycopeptide antibiotics for the treatment of
suspected methicillin-resistant nosocomial pneumonia: a meta-analysis of
randomized controlled trials, Chest 139:11481155, 2011.
SUGGESTED READINGS
Gould IM etal.: New insights into methicillin-resistant Staphylococcus aureus
(MRSA) pathogenesis, treatment and resistance, Int J Antimicrob Agents
39(2):96104, 2012.
Holland TL etal.: Clinical management of Staphylococcus aureus bacteremia, a
review, JAMA 312(13):13301341, 2014.
Liv C etal.: Clinical practice guidelines by the Infectious Diseases Society of
America for the treatment of methicillin resistant Staphylococcus aureus infections in adults and children, Clin Infect Dis 52:285292, 2011.
McConeghy K etal.: Agents for the decolonization of methicillin resistant.
Staphylococcus aureus, Pharmacotherapy 29:263280, 2009.
Wunderink RG etal.: Linezolid in methicillin-resistant Staphylococcus aureus
nosocomial pneumonia: a randomized, controlled study, Clin Infect Dis
54:621629, 2012.
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